Effective Date: 3/2/2017. Eileen Pride

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1 Title: Financial Assistance Originator: Patient Financial Services Approved by: Effective Date: 3/2/2017 Eileen Pride PFS POLICY AND PROCEDURE MANUAL Procedure Number: PFS.FIN.01 Review/Revision Date: 3/2/2017 A. Supervisor/Manager B. Asst. Department Director C. Sr. Director, Patient Financial Services POLICY: UM Capital Region Health is committed to providing financial assistance to persons who have health care needs and are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay, for emergent and medically necessary care based on their individual financial situation. It is the policy of the UM Capital Region Health Entities to provide Financial Assistance based on indigence or high medical expenses for patients who meet specified financial criteria and request such assistance. The purpose of the following policy statement is to describe how applications for Financial Assistance should be made, the criteria for eligibility, and the steps for processing applications. DHS Entities will publish the availability of Financial Assistance on a yearly basis in their local newspapers and will post notices of availability at appropriate intake locations as well as the Billing Office. Notice of availability will also be sent to patients with patient bills. Signage in key patient access areas will be made available. A Patient Billing and Financial Assistance Information Sheet will be provided before discharge and will be available to all patients upon request. Financial Assistance may be extended when a review of a patient's individual financial circumstances has been conducted and documented. This should include a review of the patient's existing medical expenses and obligations (including any accounts having gone to bad debt except those accounts that have gone to lawsuit and a judgment has been obtained) and any projected medical expenses. Financial Assistance Applications may be offered to patients whose accounts are with a collection agency and may apply only to those accounts on which a judgment has not been granted. DHS retains the right in its sole discretion to determine a patient s ability to pay. All patients presenting for emergency services will be treated regardless of their ability to pay. For emergent/urgent services, applications to the Financial Clearance Program will be completed, received, and evaluated retrospectively and will not delay patients from receiving care. PROGRAM ELIGIBILITY Consistent with their mission to deliver compassionate and high quality healthcare services and to advocate for those who do not have the means to pay for medically necessary care, UM Capital Region Health hospitals strive to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. Specific exclusions to coverage under the Financial Assistance program include the following:

2 Page: 2 of 8 1. Services provided by healthcare providers not affiliated with UM Capital Region Health hospitals (e.g., durable medical equipment, home health services) 2. Patients whose insurance program or policy denies coverage for services by their insurance company (e.g., HMO, PPO, or Workers Compensation), are not eligible for the Financial Assistance Program. a. Generally, the Financial Assistance Program is not available to cover services that are denied by a patient s insurance company; however, exceptions may be made on a case by case basis considering medical and programmatic implications. 3. Unpaid balances resulting from cosmetic or other non-medically necessary services 4. Patient convenience items 5. Patient meals and lodging 6. Physician charges related to the date of service are excluded from DHS financial assistance policy. Patients who wish to pursue financial assistance for physician-related bills must contact the physician directly. Patients may be ineligible for Financial Assistance for the following reasons: 1. Refusal to provide requested documentation or provide incomplete information. 2. Have insurance coverage through an HMO, PPO, Workers Compensation, Medicaid, or other insurance programs that deny access to the hospital due to insurance plan restrictions/limits. 3. Failure to pay co-payments as required by the Financial Assistance Program. 4. Failure to keep current on existing payment arrangements with DHS. 5. Failure to make appropriate arrangements on past payment obligations owed to UM Capital Region Health (including those patients who were referred to an outside collection agency for a previous debt). 6. Refusal to be screened for other assistance programs prior to submitting an application to the Financial Clearance Program. 7. Refusal to divulge information pertaining to a pending legal liability claim 8. Foreign-nationals traveling to the United States seeking elective, non-emergent medical care Patients who become ineligible for the program will be required to pay any open balances and may be submitted to a bad debt service if the balance remains unpaid in the agreed upon time periods. Patients who indicate they are unemployed and have no insurance coverage shall be required to submit a Financial Assistance Application unless they meet Presumptive Financial Assistance Eligibility criteria. If the patient qualifies for COBRA coverage, patient's financial ability to pay COBRA insurance premiums shall be reviewed by the Financial Counselor/Coordinator and recommendations shall be made to Senior Leadership. Individuals with the financial capacity to purchase health insurance shall be encouraged to do so, as a means of assuring access to health care services and for their overall personal health. Coverage amounts will be calculated based upon % of income as defined by federal poverty guidelines published each year in the Federal Register. The new guidelines are effective with the first month following publication. Presumptive Financial Assistance Patients may also be considered for Presumptive Financial Assistance Eligibility. There are instances when a patient may appear eligible for financial assistance, but there is no financial assistance form on file. There is adequate information provided by the patient or through other sources, which provide sufficient evidence to provide the patient with financial assistance. In the event there is no evidence to support a patient's eligibility for financial assistance, UM Capital Region Health reserves the right to use outside agencies or information in determining estimated income amounts for the basis of determining financial assistance eligibility and potential reduced care rates. Once determined, due to the inherent nature of presumptive circumstances, the only financial assistance that can be granted is a 100% write-off of the account balance. Presumptive Financial Assistance Eligibility shall only cover the patient's specific date of service. Presumptive eligibility may be determined on the basis of individual life circumstances that may include:

3 Page: 3 of 8 a. Active Medical Assistance pharmacy coverage b. SLMB coverage c. PAC coverage d. Homelessness e. Medical Assistance and Medicaid Managed Care patients for services provided in the ER beyond the coverage of these programs f. Medical Assistance spend down amounts g. Eligibility for other state or local assistance programs h. Patient is deceased with no known estate i. Patients that are determined to meet eligibility criteria established under former State Only Medical Assistance Program j. Non-US Citizens deemed non-compliant k. Non-Eligible Medical Assistance services for Medical Assistance eligible patients l. Unidentified patients (Doe accounts that we have exhausted all efforts to locate and/or ID) m. Bankruptcy, by law, as mandated by the federal courts Specific services or criteria that are ineligible for Presumptive Financial Assistance include: a. Purely elective procedures (example Cosmetic) are not covered under the program. b. Uninsured patients seen in the Emergency Department under Emergency Petition will not be considered under the presumptive financial assistance program until the Maryland Medicaid Psych program has been billed. PROCEDURES 1. There are designated persons who will be responsible for taking Financial Assistance applications. These staff can be Financial Counselors, Patient Financial Receivable Coordinators, Customer Service Representatives, etc. 2. Every possible effort will be made to provide financial clearance prior to date of service. Where possible, designated staff will consult via phone or meet with patients who request Financial Assistance to determine if they meet preliminary criteria for assistance. a. Staff will complete an eligibility check with the Medicaid program for Self-Pay patients to verify whether the patient has current coverage. b. Preliminary data will be entered into a third party data exchange system to determine probable eligibility. To facilitate this process each applicant must provide information about family size and income. To help applicants complete the process, we will provide an application that will let them know what paperwork is required for a final determination of eligibility. c. Applications initiated by the patient will be tracked, worked and eligibility determined within the third party data and workflow tool. A letter of final determination will be submitted to each patient that has formally requested financial assistance. Determination of Probable Eligibility will be provided within two business days following a patient s request for charity care services, application for medical assistance, or both d. Upon receipt of the patient s application, they will have thirty (30) days to submit the required documentation to be considered for eligibility. If no data is received within the 30 days, a denial

4 Page: 4 of 8 letter will be sent notifying that the case is now closed for lack of the required documentation. The patient may re-apply to the program and initiate a new case if the original timeline is not adhered to. The Financial Assistance application process will be open up to at least 240 days after the first post-discharge patient bill is sent. e. Individual notice regarding the hospital s charity care policy shall be provided at the time of preadmission or admission to each person who seeks services in the hospital. 3. There will be one application process for all UM Capital Region Health facilities. The patient is required to provide a completed Financial Assistance Application orally or in writing. In addition, the following may be required: a. A copy of their most recent Federal Income Tax Return (if married and filing separately, then also a copy spouse's tax return); proof of disability income (if applicable), proof of social security income (if applicable). If unemployed, reasonable proof of unemployment such as statement from the Office of Unemployment Insurance, a statement from current source of financial support, etc... b. A copy of their most recent pay stubs (if employed) or other evidence of income. c. A Medical Assistance Notice of Determination (if applicable). d. Copy of their Mortgage or Rent bill (if applicable), or written documentation of their current living/housing situation. A written request for missing information will be sent to the patient. Oral submission of needed information will be accepted, where appropriate. 4. A patient can qualify for Financial Assistance either through lack of sufficient insurance or excessive medical expenses. Once a patient has submitted all the required information, the Financial Counselor will review and analyze the application and forward it to the Patient Financial Services Department for final determination of eligibility based on DHS guidelines. a. If the patient's application for Financial Assistance is determined to be complete and appropriate, the Financial Coordinator will recommend the patient's level of eligibility and forward for a second and final approval. i) If the patient does qualify for Financial Assistance, the Financial Coordinator will notify clinical staff who may then schedule the patient for the appropriate hospital-based service. ii) If the patient does not qualify for Financial Assistance, the Financial Coordinator will notify the clinical staff of the determination and the non-emergent/urgent hospital-based services will not be scheduled. (1) A decision that the patient may not be scheduled for hospital-based, nonemergent/urgent services may be reconsidered by the Financial Clearance Executive Committee, upon the request. (2) The Financial Clearance Committee consists of Asst. Director of PFS, Sr Director of Revenue Cycle, DHS Risk Manager, and CFO. (3) The CFO shall sign off on any charity cases greater than $50, Each clinical department has the option to designate certain elective procedures for which no Financial Assistance options will be given. 6. Once a patient is approved for Financial Assistance, Financial Assistance coverage may be effective for the month of determination, up to 3 years prior, and up to six (6) calendar months in to the future. However, there are no limitations on the Financial Assistance eligibility period. Each eligibility period will be determined on a case-by-case basis. If additional healthcare services are provided beyond the approval period, patients must reapply to the program for clearance. In addition, changes to the patient s income, assets, expenses or family status are expected to be communicated to the Financial Assistance Program Department. All Extraordinary Collections Action activities, as defined below, will

5 Page: 5 of 8 be terminated once the patient is approved for financial assistance and all the patient responsible balances are paid. Extraordinary Collection Actions (ECAs) may be taken on accounts that have not been disputed or are not on a payment arrangement. Except in exceptional circumstances, these actions will occur no earlier than 120 days from submission of first bill to the patient and will be preceded by notice 30 days prior to commencement of the ECA action. Availability of financial assistance will be communicated to the patient and a presumptive eligibility review will occur prior to any action being taken. i) Garnishments may be applied to these patients if awarded judgment. ii) iii) A lien may be placed by the Court on primary residences. The facility will not pursue foreclosure of a primary residence but may maintain our position as a secured creditor if a property is otherwise foreclosed upon. Closed account balances that appear on a credit report or referred for judgment/garnishment may be reopened should the patient contact the facility regarding the balance report. Payment will be expected from the patient to resolve any credit issues, until the facility deems the balance should remain written off. iv) Extraordinary Collection Actions require the approval of the Financial Clearance Committee. 7. If a patient is determined to be ineligible, all efforts to collect co-pays, deductibles or a percentage of the expected balance for the service will be made prior to the date of service or may be scheduled for collection on the date of service. 8. A letter of final determination will be submitted to each patient who has formally submitted an application. 9. Refund decisions are based on when the patient was determined unable to pay compared to when the patient payments were made. Refunds may be issued back to the patient for credit balances, due to patient payments, resulted from approved financial assistance on considered balance(s). Payments received for care rendered during the financial assistance eligibility window will be refunded, if the amount exceeds the patient s determined responsibility by $5.00 or more. 10. Patients who have access to other medical care (e.g., primary and secondary insurance coverage or a required service provider, also known as a carve-out), must utilize and exhaust their network benefits before applying for the Financial Assistance Program. Financial Hardship The amount of uninsured medical costs incurred at any UM Capital Region Health facility will be considered in determining a patient s eligibility for the Financial Assistance Program. The following guidelines are outlined as a separate, supplemental determination of Financial Assistance, known as Financial Hardship. Financial Hardship will be offered to all patients who apply for Financial Assistance. Medical Financial Hardship Assistance is available for patients who otherwise do not qualify for Financial Assistance under the primary guidelines of this policy, but for whom: 1) Their medical debt incurred at UM Capital Region Health facilities exceeds 25% of the Family Annual Household Income, which is creating Medical Financial Hardship; and 2) who meet the income standards for this level of Assistance.

6 Page: 6 of 8 For the patients who are eligible for both the Reduced Cost Care under the primary Financial Assistance criteria and also under the Financial Hardship Assistance criteria, UM Capital Region Health will grant the reduction in charges that are most favorable to the patient for medically necessary treatment by a family household over a twelve (12) month period that exceeds 25% of that family s annual income. Medical Debt is defined as out of pocket expenses for the facility charges incurred for medically necessary treatment. Once a patient is approved for Financial Hardship Assistance, coverage will be effective starting the month of the first qualifying date of service and up to the following twelve (12) calendar months from the application evaluation completion date. Each patient will be evaluated on a case-by-case basis for the eligibility time frame according to their spell of illness/episode of care. It will cover the patient and the immediate family members living in the household for the approved reduced cost and eligibility period for medically necessary treatment. Coverage shall not apply to elective or cosmetic procedures. However, the patient or guarantor must notify the hospital of their eligibility at the time of registration or admission. In order to continue in the program after the expiration of each eligibility approval period, each patient must reapply to be reconsidered. In addition, patients who have been approved for the program must inform the hospitals of any changes in income, assets, expenses, or family (household) status within 30 days of such change(s). All other eligibility, ineligibility, and procedures for the primary Financial Assistance program criteria apply for the Financial Hardship Assistance criteria, unless otherwise stated above. Appeals Patients whose financial assistance applications are denied have the option to appeal the decision. Appeals can be initiated verbally or written. Patients are encouraged to submit additional supporting documentation justifying why the denial should be overturned. Appeals are documented within the third party data and workflow tool. They are then reviewed by the next level of management above the representative who denied the original application. If the first level of appeal does not result in the denial being overturned, patients have the option of escalating to the next level of management for additional reconsideration. The escalation can progress up to the Chief Financial Officer who will render a final decision. A letter of final determination will be submitted to each patient who has formally submitted an appeal. Judgments If a patient is later found to be eligible for Financial Assistance after a judgment has been obtained or the debt submitted to a credit reporting agency, UM Capital Region Health shall seek to vacate the judgment and/or strike the adverse credit information.

7 Page: 7 of 8 % Of Write Off 100% 100% 70% 60% 50% 25% Family Size Income Income Income Income Income Income 1 $12,060 $24,120 $27,135 $30,150 $36,180 $60,300 2 $16,240 $32,480 $36,540 $40,600 $48,720 $81,200 3 $20,420 $40,840 $45,945 $51,050 $61,260 $102,100 4 $24,600 $49,200 $55,350 $61,500 $73,800 $123,000 5 $28,780 $57,560 $64,755 $71,950 $86,340 $143,900 6 $32,960 $65,920 $74,160 $82,400 $98,880 $164,800 7 $37,140 $74,280 $83,565 $92,850 $111,420 $185,700 8 $41,320 $82,640 $92,970 $103,300 $123,960 $206,600 For families/households with more than 8 persons, add $ 4,180 for each additional person. % of Income at or above 2017 Poverty Guidelines 100% 200% 225% 250% 300% 500%

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